HIH Implementation Specification for AR2017.07€¦ · Transaction data validation and...

Centers for Medicare & Medicaid Services CMS eXpedited Life Cycle (XLC)

Electronic Submission of Medical Documentation (esMD)

Release AR2017.07.0 X12N 275 HIH Implementation Specification

Version 1.2 Final

05/02/2017

Document Number: AR2017.07.0_X12N275_HIH_Imp_Spec

Contract Number: HHSM-500-2015-00146U

Table of Contents

Release AR2017.07.0 X12N 275 HIH Implementation Specification Version 1.2 Final ii Electronic Submission of Medical Documentation (esMD)

Table of Contents

1. Introduction .............................................................................................................. 1

1.1 Purpose ........................................................................................................... 1 1.2 Scope .............................................................................................................. 1

2. Use Case ................................................................................................................... 2

2.1 Assumptions .................................................................................................... 2 2.2 Actors and Roles ............................................................................................. 2 2.3 User Story Additional Documentation for Review ......................................... 3

3. X12N 275 Process Flow ........................................................................................... 5

4. Communication Protocol Specification ................................................................. 8

4.1 CAQH CORE Batch Transaction Web Service Endpoints .............................. 8 4.2 CAQH CORE Envelope Specification ........................................................... 10 4.3 CAQH CORE Generic Batch Mode Messaging ............................................. 10 4.4 CAQH CORE Metadata Information .............................................................. 11

5. ASC X12N275 Supplemental Information ............................................................ 13

5.1 X12 Version Information ................................................................................ 13 5.2 esMD-Specific Business Rules and Limitations ............................................ 13 5.3 Clinical Document Information ...................................................................... 17

6. Response Notification and Error Codes .............................................................. 17

6.1 Interchange Acknowledgement (X12 TA1) .................................................... 17 6.2 Implementation Acknowledgement (X12N 999) ............................................ 17 6.3 Envelope Processing Status and Error Codes .............................................. 17 6.4 Administrative Errors ..................................................................................... 18

7. Sample Files ........................................................................................................... 18

Appendix A: Record of Changes ........................................................................ 22

Appendix B: Acronyms ....................................................................................... 23

Appendix C: Referenced Documents ................................................................. 24

List of Figures

Figure 1: Business Use Case .......................................................................................... 4

Figure 2: B2B X12N 278 and X12N 275 Information Flow Diagram ................................ 6

Figure 3: ASC X12N 275 CONNECT (CAQH CORE) Envelope ................................... 10

List of Tables

Release AR2017.07.0 X12N 275 HIH Implementation Specification Version 1.2 Final iii Electronic Submission of Medical Documentation (esMD)

Figure 4: esMD_Sample_278_EDI_Request ................................................................ 18

Figure 5: esMD_Sample_275_EDI_Batch_Request ..................................................... 19

List of Tables

Table 1: Business Actors and Roles................................................................................ 3

Table 2: X12N 278 and X12N 275 Message Sequence .................................................. 7

Table 3: Web Service Details .......................................................................................... 9

Table 4: Required CAQH CORE Request Metadata Elements ..................................... 11

Table 5: CAQH CORE Response Metadata Elements .................................................. 12

Table 6: Transaction Type Supported Version .............................................................. 13

Table 7: Interchange Delimiter ...................................................................................... 14

Table 8: X12N 275 Transaction Segments .................................................................... 15

Table 9: X12N 275 Transaction Allowed Codes ............................................................ 16

Table 10: X12N 278 and X12N 275 Data Element Interdependency Matrix .................. 16

Table 11: Envelope Processing Status and Errors ........................................................ 17

Table 12: Record of Changes ....................................................................................... 22

Table 13: Acronyms ...................................................................................................... 23

Table 14: Referenced Documents ................................................................................. 24

Introduction

Release AR2017.07.0 X12N 275 HIH Implementation Specification 1 Electronic Submission of Medical Documentation (esMD) Version 1.2 Final

1. Introduction

This specification document provides the standardized data structure and content that must be adhered to by all trading partners participating in the Accredited Standards Committee (ASC)/X12N 006020 275 batch transaction.

This document contains the prerequisite information required to furnish the X12N 275 batch transactions in order to process them through Electronic Submission of Medical Documentation (esMD) system electronically.

This document must be used in conjunction with Health Level 7 (HL7)-Clinical Data Architecture (CDA) Implementation Standards, ASC/X12N 006020 275 TR3, Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) operating rules and the Centers for Medicare & Medicaid Services (CMS) HIH Implementation Guide. This document directs implementers to the appropriate version of X12N 275 Electronic Data Interchange (EDI), CDA template standards and the surrounding CAQH metadata required for formation of request.

The audience of this supplement are implementers, such as architects and developers, responsible for the exchange of supporting/attachment information among healthcare providers, Health Information Handlers (HIH), and their business associates, such as CMS.

1.1 Purpose

This document outlines the technical aspect of X12N 275 information flow process and provides an overview of procedures required to be adopted for X12N 275 submission. The main purposes are to:

1. Provide the high-level business use case of X12N 275 communication between HIHs and the esMD system;

2. Provide the list of guidelines or operating rules required for establishing the contract between the Business To Business (B2B) component of HIHs (i.e., trading partner) and esMD while transporting Prior Authorization (PA) documentation in form of X12N 275 EDI;

3. Provide the list of data elements required in the X12N 275 EDI and CAQH core envelope; and

4. Provide the high-level structure of possible responses/acknowledgments sent to HIHs from esMD.

This document does not address installation and configuration details of actual implementation.

1.2 Scope

This specification document is intended for HIHs to submit X12N 275 transactions with CMS.

This document provides the information needed to initiate and maintain communication exchange with the esMD CAQH batch service to regulate X12N 275 (Attachment) batch submission. This specification document supplements the ASC/X12N 006020 275 TR3 document and CAQH CORE operating rules.

This document targets the exchange of X12N 275 (unsolicited) transactions, adopting the standard of CAQH CORE that may already exist in both the initiators and consumers systems or may need to be created for this exchange.

Use Case


Guidance is provided on associating the clinical attachment, CAQH metadata, X12N 275, and X12N 278 and their technical importance with appropriate examples. Information is also provided on methods (e.g., transport, networking, connectivity, security/privacy) of exchange and appropriate usage of CONNECT CAQH Web Services Definition Language (WSDL) and/or operations.

2. Use Case

The esMD initiative to accept additional supporting documentation for review in form of X12N 275 batch submission focuses on business use case of secure transportation of medical documentation from the HIH to the Review Contractor (RC).

2.1 Assumptions

The esMD system complies with industry standards defined by various standards committee. Hence, it is extremely important that esMD participants adhere to the norms with the following assumptions:

1. The esMD additional documentation for review will be sent by the HIH in the form of X12N 275 EDI requests based on the standards set by the ASC committee;

2. All transactions will utilize industry-accepted standards, where available, and must have appropriate security to ensure data is transmitted with integrity, confidentiality, and reliability; and with authentication of both the sender and receiver;

3. It is the responsibility of an agent or gateway to ensure reliability and consistency of any transformation of information;

4. An X12N 275 transaction must be submitted within 4 business days after initiating the PA request of X12N 278;

5. The Cross-Enterprise Document Reliable Interchange (XDR) submission with Content Type Code (CTC) 13 will continue to be accepted by esMD;

6. An X12N 275 transaction must have all relevant information per esMD guidelines and must match the X12N 278 request;

7. A CONNECT-compatible gateway must be used by the HIHs or trading partner for transporting additional documentation; and

8. All transactions must adhere to the standards set by the Sequoia Project (formerly known as the Healtheway, or Nationwide Health Information Network (NwHIN)).

2.2 Actors and Roles

The Table 1: Business Actors and Roles summarizes the business actors that directly interact with esMD and participate in transportation of X12N 275 additional documentation for review exchange.

Use Case


Table 1: Business Actors and Roles

Business Actor System Role

esMD Gateway CMS Connect Gateway 1. Establish B2B secure communication;

2. Transaction data validation and

verification;

3. Virus detection;

4. Transaction auditing and logging;

5. Error handling and email notification;

6. Transform transaction in recipient-

acceptable format;

7. Route transactions to appropriate

destinations; and

8. Acknowledge and report transaction

statuses.

Health Information

Handler (HIH)

esMD Trading Partner

Information System/Provider

Agent

1. Collect, transform, and transport

medical/additional documentation to RCs

through esMD; and

2. Send to providers the medical review

results received from RCs

Review Contractor

(RC)

CMS Requests medical

documentation as needed and

reviews submitted medical

documentation to determine

compliance with

Medicare/Medicaid rules for

Claims and for PA Requests.

1. Requestor of additional documentation

2. Review additional documentation; and

3. Provide review result to providers/HIH.

2.3 User Story Additional Documentation for Review

To avoid any improper payment or control potential fraud and abuse, RCs require evidence of the medical necessity for the services to be provided or for the services already provided, as well as evidence that the services were provided to the patient for whom the services have been billed and/or to complete the PA, pre-claim, or claim review in accordance with Medicare/Medicaid rules and regulations. See Figure 1: Business Use Case and the following:

1. The RC sends a medical documentation request letter (paper or electronic) to inform the providers that they have been selected for a review and request the provider to provide specific medical documentation to complete the review process;

2. The healthcare provider may use third party agent HIH gateway service to respond to the RC requests for medical documentation by transmitting additional medical document through esMD system;

3. Once esMD system receives the submission from HIH it validates the credential, agreement, data compliance against esMD guidelines, transforms, translates and routes the request to the appropriate review contractors;

4. The esMD system acknowledges receipt of any submission from the HIH or RC with appropriate status; and

5. The RC inspects the documentation sent by the provider and sends the review results or decision through the esMD gateway.

Use Case


Figure 1: Business Use Case

X12N 275 Process Flow


3. X12N 275 Process Flow

Figure 2: B2B X12N 278 and X12N 275 Information Flow Diagram depicts the X12N 278 5010 workflow with additional X12N 275 6020 document submission(s) and the PA Review Responses. Each request or submission followed by synchronous response (shown in a single white rectangle) is in a client-server Hypertext Transfer Protocol (HTTP)/HTTP Secure (HTTPS) connection that are expected to be opened for a request and closed after the corresponding synchronous response is received.



Figure 2: B2B X12N 278 and X12N 275 Information Flow Diagram



Table 2: X12N 278 and X12N 275 Message Sequence describes the typical interaction as shown in Figure 2: B2B X12N 278 and X12N 275 Information Flow Diagram.

Note: The further processing of the pickup notification and review result response for the PA request will continue as defined in Section 11.4 of the HIH Implementation Guide.

Table 2: X12N 278 and X12N 275 Message Sequence

Message Sequence

Description

1.1 The HIH sends the real-time X12N 278 5010 PA Request in CAQH format, i.e., COREEnvelopeRealTimeRequest with PayloadType = X12_278_Request_005010X217E1_2) to the esMD

1.2 The esMD system processes the PA request and generates the appropriate response in CAQH CORE Real-Time Mode (Synchronous). One of the below possible responses is

sent to the HIH in CAQH format, i.e., COREEnvelopeRealTimeResponse: a. X12N 999 5010 (Ack): Reports any functional group level syntactical compliance

error identified in X12N 278 5010 request;

b. X12N TA1 5010 (Ack): Reports any syntactical error encountered at the interchange level;

c. X12N 278 5010 (AAA): Reports invalid workload/intended recipient identifier value

submitted in the Utilization Management Organization (UMO) NM1-09 of X12N 278 5010 request;

d. CORE Envelope Error: Reports an CAQH metadata or any error that halts esMD to process the request further; and

e. X12N 278 5010 Response: Confirms the acceptance of the X12N 278 5010 request and awaits the supporting document.

1.3 The esMD waits for the additional documentation to be sent by the HIH in X12N 275 6020 batch Submission enveloped in CAQH format, i.e., COREEnvelopeBatchSubmission: a. If esMD does not receive the additional documentation within 2 business days, then

the X12N 278 5010 deferred response with a pending status is generated by esMD and sent to the HIH; and

b. The HIH responds to the 2-day notification with an X12N 999 success status or a 999 error/TA1 acknowledgement in case of an error.

1.4 The esMD waits for the additional documentation to be sent by the HIH in the X12N 275 6020 batch Submission enveloped in CAQH format, i.e., COREEnvelopeBatchSubmission: a. If esMD does not receive the additional documentation within 4 business days, then

the X12N 278 5010 deferred response with a cancelation status is generated by esMD and sent to the HIH; and

b. The HIH responds to the 4-day notification with an X12N 999 success status or a 999 error/TA1 acknowledgement in case of an error.

2.1 The HIH sends the additional documentation to esMD using the X12N 275 batch Submission enveloped in CAQH format, i.e., COREEnvelopeBatchSubmission, having the appropriate payload type in the submissions (i.e., payload type= X12_275_Request_006020X316).

2.2 The esMD responds (synchronously to request message 2.1) to the batch request either with an HTTP level error or an HTTP successful response accompanied by a CORE envelope level response, indicating the batch was received (e.g., payload type = X12_275_Response_006020X316) indicating the CORE envelope was accepted (with or without errors) in esMD.

Communication Protocol Specification


Message Sequence

Description

2.3 The esMD validates the CAQH CORE envelope metadata, performs the X12N 275 additional documentation compliance check, and sends the acknowledgement (i.e., either payload type = X12_999_Response_005010X231A1 or payload type =X12_TA1_Response_005010X231A1) accompanied by a CORE envelope-level response (or error), i.e., COREEnvelopeBatchSubmission.

2.4 The HIH responds (synchronously to request message 2.3) to the esMD acknowledgement with appropriate information stating that the esMD acknowledgement response was received. The ErrorCode element in COREEnvelopeBatchSubmissionResponse must be set to either Success or Failure.

4. Communication Protocol Specification

The esMD has provided connectivity that complies with the Sequoia Project (formerly known as the Healtheway and NwHIN) Phase II CAQH CORE Rule 270: Connectivity Rule Version 2.2.0 to exchange ASC X12 Administrative Transactions with HIHs via the Internet. CONNECT support for CAQH Profile has been implemented as part of the CONNECT release 4.4.

4.1 CAQH CORE Batch Transaction Web Service Endpoints

The initiating HIH and receiving esMD gain or share access to their secure CONNECT gateways using the unique endpoint Universal Resource Locater (URL) exposed publicly over the internet. Table 3: Web Service Details describes the CAQH CORE batch submission and deferred response endpoints information that each trading partner participating in X12N 275 must disclose for exchanging additional supporting documentation and its acknowledgements.



Table 3: Web Service Details

Service Name Endpoint Description

GenericBatchTransaction

(Request: HIH to esMD)

https://xxxxxxxx:xxxx

/Gateway/CORE_X12DocumentSubmission/1_0/GenericBatchRequestTrans

action_Service

NHIN Used for

communication between

HIHs and the esMD gateway

EntityCOREGenericBatchTr

ansactionUnSecured

(Request: HIH internal

purpose)

http://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/EntitySe

rvice/EntityCOREGenericBatchRequestUnsecured

Entity Used for

communicating within the

internal gateway adapters

GenericBatchTransaction

Response

(Response: esMD to HIH)

https://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/Generic

BatchResponseTransaction_Service

NHIN - Used for

communication between

esMD and the HIH gateway

EntityCOREGenericBatchTr

ansactionUnSecured

(Response: Internal to

esMD)

http://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/EntitySe

rvice/EntityCOREGenericBatchResponseUnsecured

Entity - Used for

communicating within the

internal gateway adapters

https://xxxxxxxx:xxxx%20/Gateway/CORE_X12DocumentSubmission/1_0/GenericBatchRequestTransaction_Service%20https://xxxxxxxx:xxxx%20/Gateway/CORE_X12DocumentSubmission/1_0/GenericBatchRequestTransaction_Service%20https://xxxxxxxx:xxxx%20/Gateway/CORE_X12DocumentSubmission/1_0/GenericBatchRequestTransaction_Service%20http://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/EntityService/EntityCOREGenericBatchRequestUnsecuredhttp://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/EntityService/EntityCOREGenericBatchRequestUnsecuredhttps://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/GenericBatchResponseTransaction_Servicehttps://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/GenericBatchResponseTransaction_Servicehttp://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/EntityService/EntityCOREGenericBatchResponseUnsecuredhttp://xxxxxxxx:xxxx/Gateway/CORE_X12DocumentSubmission/1_0/EntityService/EntityCOREGenericBatchResponseUnsecured



4.2 CAQH CORE Envelope Specification

The CAQH CORE X12 Document Submission Service Interface Specification defines specific constraints on the structure of the CAQH CORE envelope. Figure 3: ASC X12N 275 CONNECT (CAQH CORE) Envelope depicts the structure of the request message of the CAQH CORE X12 Document Submission Service interface.

The current supported protocol for CAQH CORE is HTTP/S. This rule is based on the following standards and versions:

1. HTTP Version 1.1; 2. Secure Sockets Layer (SSL) Version 3.0; 3. Multipurpose Internet Mail Extension (MIME) Version 1.0; 4. The MIME Multipart/Form-Data (IETF RFC 2388); 5. Simple Object Access Protocol (SOAP) Version 1.2; 6. WSDL Version 1.1; and 7. Web Service-Security 1.1.

Figure 3: ASC X12N 275 CONNECT (CAQH CORE) Envelope

4.3 CAQH CORE Generic Batch Mode Messaging

esMD uses the CAQH CORE service interface specifications with SOAP envelope messages over web service interfaces for transmitting additional documentation in the form of an X12N



275 EDI transaction. The HIH shall use the batch mode, i.e., COREEnvelopeBatchSubmission, for sending X12N 275 requests to the esMD system.

The esMD and HIH communication flow is as follows:

1. The HIH initiates the SOAP Messages to esMD with Security Assertion Markup Language (SAML) Assertions, Payload/CAQH Metadata, and X12 275 with embedded HL7 clinical information (C62 or CCDA) in the SOAP Body after opening the Hypertext Transfer Protocol Secure (HTTPS) connection. Refer to Section 4.4 CAQH CORE Metadata Information for details on the envelope metadata attribute and its definition;

2. The esMD gateway acknowledges the acceptance of the request to HIH with the appropriate status and message on the same HTTPS connection opened by the HIH Gateway. This receipt acknowledgement response is considered to be confirmation of successful transmission of request to esMD, but yet to be validated and processed by esMD.

3. The esMD system shall send the notification, i.e., the X12N 999 (Acceptance/Rejection)/X12TA1 or CORE envelope error, using the Batch transmission mode (i.e., deferred messaging).

Note: Further notifications may be in form of X12N278 awaiting decision.

4.4 CAQH CORE Metadata Information

The esMD system uses the set of metadata defined under CAQH CORE Rule 270 Version 2.2.0

for message routing, transaction auditing, transaction scheduling, resource allocation, backward

compatibility, error handling, and audit logging. The required CAQH CORE Metadata for the

esMD (COREEnvelopeBatchSubmission and COREEnvelopeBatchSubmissionResponse) are

listed in Table 4: Required CAQH CORE Request Metadata Elements and Table 5: CAQH

CORE Response Metadata Elements.

Table 4: Required CAQH CORE Request Metadata Elements

CAQH CORE Element

Description

PayloadType Payload Type specifies the type of payload included within the request.

esMD accepted value: X12_275_Request_006020X316

ProcessingMode esMD accepted value: Batch

PayloadLength Specifies the length of the actual payload, i.e., X12N275 EDI in bytes.

PayloadID A Unique ID must be submitted in each submission. The length must not exceed

80 alphanumeric characters.

TimeStamp Request Message creation time in Coordinated Universal Timestamp (UTC)

format (yyyy-MM-ddTHH:mm:ssZ). Ex: 2007-08-30T10:20:34Z

SenderID Unique business entity identifier representing the message creator. Valid HIH

Organizational Identifier (OID) is required.

ReceiverID Unique business entity identifier representing the message receiver. Valid RC

OID is required.



CAQH CORE Element

Description

CORERuleVersion The CORE Rule version that this envelope is using 2.2.0

esMD accepted value: 2.2.0

CheckSum An element used to allow the receiving site to verify the integrity of the message

that is sent.

Algorithm is SHA-1. Encoding is hexadecimal. Checksum must be computed

only on the X12 payload and not on the metadata.

Payload Base64-encoded string Payload must be embedded.

Table 5: CAQH CORE Response Metadata Elements

CAQH CORE Element

Description

PayloadType Payload Type specifies the type of payload included within the request.

Possible values:

X12_275_ACK_006020X316

X12_TA1_Response_005010X231A1

X12_999_Response_005010X231A1

ProcessingMode esMD recommended value: Batch

PayloadLength Specifies the length of the actual payload, i.e., X12N999/TA1 in bytes. The value

will be set only if payload is sent in the response.

PayloadID The initial request unique ID will be returned.

TimeStamp Message creation time in UTC format (yyyy-MM-ddTHH:mm:ssZ). For example:

2007-08-30T10:20:34Z

SenderID Unique business entity identifier representing the message creator. esMD-OID is

provided.

ReceiverID Unique business entity identifier representing the message receiver. HIH-OID is

provided.

CORERuleVersion The CORE Rule version that this envelope is using 2.2.0

esMD value: 2.2.0

CheckSum An element used to allow the receiving site to verify the integrity of the message

that is sent.

Algorithm is SHA-1. Encoding is hexadecimal. Checksum must be computed

only on the payload and not on the metadata. The value will be set only if

payload is sent in response.

Payload Base64-encoded string Payload may be embedded.

ErrorCode Error code to indicate the esMD proprietary error when processing the envelope.

ASC X12N275 Supplemental Information


CAQH CORE Element

Description

ErrorMessage Text Error message that describes the condition that caused the error. The text

of the ErrorMessage must provide additional information describing how the

Error can be resolved, and must not provide conflicting information from that

provided in the ErrorCode.

5. ASC X12N275 Supplemental Information

This section provides assistance to the trading partners or HIHs in implementing the ASC X12N/006020X316 version of EDI 275 transaction (Additional Information to Support a Health Care Service Review) to meet esMD processing standards. It provides detailed explanations of the transaction set by defining data content, identifying valid code values as per the esMD PA programs and its supporting documentation norms, and describing values that are applicable for X12N 275 Additional Information with respect to esMD.

The esMD trading partners, such as HIHs, must adhere to the esMD-specific supplemental information along with ASC X12N/005010X217 (278) TR3 and ASC X12N/006020X316 (275) TR3 guidelines in order to effectively transmit additional documentation to their review contractors.

5.1 X12 Version Information

The esMD system supports specific version/release/industry identifier codes for processing X12N 275 transaction set and for sending any acknowledgements.

The version/release/industry identifier code mentioned in Table 6: Transaction Type Supported Version and are the applicable Functional Identifier codes that must be transmitted in the Functional Group Header (GS Segment) at the start of the functional group of an X12 transaction set.

Table 6: Transaction Type Supported Version

Standard Transaction Type Version/Release/Industry

Identifier Code

HIPAA/X12 275 (Additional Information To Support a Healthcare

Service Review)

006020X316

HIPAA/X12 999 (Implementation Acknowledgment For Health Care

Insurance)

005010X231A1

HIPAA/X12 TA1 (Interchange Acknowledgement) 005010X231A1

5.2 esMD-Specific Business Rules and Limitations

esMD imposes a few global business rules and limitations on the X12N 275 transaction in order to relate to its initial X12N 278 PA request. The following information describes the esMD X12N 275 transaction requirements to be used in conjunction with the standards outlined in the ASC X12 275 version 006020X316 TR3. Adhering to these requirements will ensure that the X12N 275 submission passes the esMD business edits.



The esMD trading partners or HIH must adhere to the following business rules and limitations for submitting transactions in batch submission mode:

1. Only one transaction per functional group; 2. Only one functional group per interchange; 3. Table 7: Interchange Delimiter depicts the preferred delimiters that esMD uses for X12

transactions that it generates; 4. Interchange acknowledgements for successful deliveries are honored for submitters

using the deferred batch response method; 5. Multiple 2000A loops (Assigned Number) are allowed to be submitted if the same

Attachment Control Number (ACN) is supplied in the TRN02 element in that loop; 6. Only one Health information (HI) code segment is allowed in each 2000A loop and the

sequence of the first five diagnosis codes and its qualifier must match the value submitted in the corresponding X12N 278 PA request. esMD will validate only the first five Diagnostic Codes submitted in the first 2000A loop. If more than five Diagnostic Codes are submitted in the first HI segment, esMD will ignore them;

7. esMD allows a maximum of 200 Megabytes (MB) for documents in one batch submission, but all documents larger than 64 MB must be reformatted into smaller fully formatted documents of not more than 64 MB wrapped with HL7 clinical Extensible Markup Language (XML). The length of the binary data in each Binary Data Segment (BDS) must not exceed 64 MB, and the binary data must be a well formed HL7 clinical XML document.;

8. Table 8: X12N 275 Transaction Segments lists the Mandatory (M) loop segments that must be submitted in the 275 transaction in accordance with the ASC X12N/006020X316 (275) TR3 Implementation Guide;

9. Table 9: X12N 275 Transaction Allowed Codes lists the constraints on the esMD-specific acceptable code value that must be supplied for an element within a segment of particular loop;

10. The receiverId provided in ISA-08 must be the EDI ID assigned to each RC. In the future, EDI IDs will be published on the esMD website. Until then, contact the esMD Service Desk to obtain the information;

11. The Transaction Set Reference Identification number provided in BGN-02 must be a unique value and must match CAQH CORE payload ID value;

12. The esMD X12N 278 transaction ID must be provided in the REF-02 (Patient Event Tracking Number) under loop 1000C (Patient Event Trace Number);

13. Table 10: X12N 278 and X12N 275 Data Element Interdependency Matrix provides the list of segment, loop, and data element of X12N 275 submission for which the value must match the corresponding X12N 278 transaction; and

14. esMD allows the submission of additional documentation in either XDR or X12N 275 format corresponding to the initial X12N 278 PA request, but both formats are not allowed. For example, if an HIH must make three submissions of additional documentation to an initial X12N 278 request, then all three submissions must be in X12N 275 format or all three submissions must be in XDR format.

Table 7: Interchange Delimiter

Character Name Delimiter * Asterisk Data Element Separator

+ Plus Component Element

Separator

~ Tilde Segment terminator

^ Carat Repetition Separator



Table 8: X12N 275 Transaction Segments

Segment ID Loop Segment Name esMD Usage

ST Not assigned Transaction Set Header M

BGN Not assigned Beginning Segment M

NM1 1000A Information Source Name M

PER 1000A Information of Source Contact Information M

NM1 1000B Information Receiver Name M

NM1 1000C Patient Name M

LX 2000A Assigned Number M

TRN 2000A Attachment Control Trace Number M

HI 2000A Healthcare Information Codes M

DTP 2100A Additional Information Submitted Date M

CAT 2100A Format and Version Identifier M

OOI 2110A Associated Object Type Identification M

BDS 2110A Binary Data Segment M

SE Not assigned Transaction Set Trailer M



Table 9: X12N 275 Transaction Allowed Codes

Name Loop Segment Element Identifier

esMD Allowable Code(s)

Information Source Identifier NA BGN BGN01 02

Information Source Identifier 1000A NM1 NM108 XX

Information Receiver Name 1000B NM1 NM102 2

Information Receiver Name 1000B NM1 NM108 PI

Information Receiver Name 1000B NM1 NM111 X3

Patient Primary Identifier 1000C NM1 NM101 IL

Patient Primary Identifier 1000C NM1 NM108 MI

Attachment Control Number 2000A TRN TRN01 1

Format And Version

Identifier

2100A CAT CAT02 HL or MB

Table 10: X12N 278 and X12N 275 Data Element Interdependency Matrix

From (X12N278: HIPAA/X12 005010X217 278Q) To (X12N275: HIPAA/X12 006020X316 275)

Name Loop Segment and Element Identifier

Name Loop Segment and Element Identifier

Requester Identifier 2010B NM109 Information Source Identifier 1000A NM109

Utilization Management

Organization Identifier

2010A NM109 Information Receiver Name 1000B NM109

Subscriber Member Number 2010C NM109 Patient Primary Identifier 1000C NM109

Attachment Control Number 2000E PWK06 Attachment Control Number 2000A TRN/NM102

Attachment Control Number 2000F PWK06 Attachment Control Number 2000A TRN/NM102

Diagnosis Type Code 2000E HI01-1 Diagnosis Type Code 2000A HI01-1

Diagnosis Code 2000E HI01-2 Diagnosis Code 2000A HI01-2









Response Notification and Error Codes


5.3 Clinical Document Information

Clinical document information defines the clinical document metadata data specification and the usage of the appropriate Healthcare Information Technology Standards Panel (HITSP) template depending on the type of C62 payload attachment. Refer to Section 10.5 Clinical Document Information in the HIH Implementation Guide.

6. Response Notification and Error Codes

Only one response or notification is sent for each X12N 275 submission: a TA1, 999, or CAQH error message.

6.1 Interchange Acknowledgement (X12 TA1)

The TA1 Interchange Acknowledgement is send by esMD to communicate the rejection of an X12N 275 submission based on errors encountered with X12 compliance or formatting of the ISA/IEA Interchange segments.

A TA1 may be returned in cases such as the following examples:

1. An X12N 275 submission is received and the X12 version of the transmission cannot be determined; and

2. An X12N 275 submission is received and the version of the transmission is unsupported by the esMD system. This includes previously accepted versions that are no longer supported.

6.2 Implementation Acknowledgement (X12N 999)

The 999 Implementation Acknowledgement is send by the esMD application to communicate the acceptance or rejection of an X12N 275 submission based on errors encountered with X12 compliance, formatting, or not meeting esMD-specific requirements within the data segments between the Functional Group Header (GS) and Functional Group Trailer (GE). Refer to the ASC X12 999 version 005010X231A1 TR3 for additional information.

6.3 Envelope Processing Status and Error Codes

The esMD custom CAQH CORE error messages is sent to the HIH if esMD fails to formulate an X12-compliant response due to CAQH CORE envelope metadata validation failure or any issue that prevents the system from processing the transaction further. Table 11: Envelope Processing Status and Errors lists a few examples of custom errors that esMD may send in response.

Table 11: Envelope Processing Status and Errors

Scenario Error Message Error Code

The CAQH CORE metadata element

Timestamp contains an invalid value

Invalid timestamp Failure


CORERuleVersion contains a value

other than V2.2.0

Invalid CoreRuleVersion Failure

Sample Files


Scenario Error Message Error Code


SenderID contains an invalid value

Sender ID does not exist Failure


ReceiverID contains an invalid value

OID provided under ReceiverID element

is not associated with the value at

ISA08/GS03

Failure


PayloadType contains an invalid value

Invalid Payload type Failure


ProcessingMode contains a value other

than Batch

Invalid processing mode Failure

The CAQH CORE element Payload

contains an invalid value

EDI Error Failure

X12 functional group fails to pass esMD-

specific edits

Error on 999 Failure

X12 interchange fails in compliance check Error on TA1 Failure

6.4 Administrative Errors

The esMD system will continue to send Administrative errors to HIH in XDR form.

7. Sample Files

The following sample X12N 278 Request and X12N 275 batch EDI files Figure 4: esMD_Sample_278_EDI_Request and Figure 5: esMD_Sample_275_EDI_Batch_Request are for illustration purposes; no real data is included .

Figure 4: esMD_Sample_278_EDI_Request

ISA*00* *00* *ZZ*TEST123 *ZZ*111222333 *170320*1010*^*00501*000002100*0*T*+~

GS*HI*TEST123*111222333*20170320*1010*2100*X*005010X217~

ST*278*2100*005010X217~

BHT*0007*13*2017032010101*20170320*1010~

HL*1**20*1~

NM1*X3*2*COBIUS*****PI*11202~

HL*2*1*21*1~

NM1*1P*2*HIHPROVIDER*****XX*1234567893~

N3*34-C TROTTER~

N4*COLUMBIA*SC*29169~

PER*IC*ESMD TESTING*FX*8034362416*TE*8034362416*EX*6788~

HL*3*2*22*1~

NM1*IL*1*PARKER*CARROL*S***MI*814030004A~

N3*430 BUCKEYE~

N4*WESTERVILLE*OH*43081~

DMG*D8*19900501*F~

Sample Files


HL*4*3*EV*1~

TRN*1*201703202100*1017032010*ESMDTESTREQUEST~

UM*HS*I*1*13+B*AA+EM+AP+ON+CA*U*3*4*Y*1~

DTP*439*D8*20170320~

DTP*ABC*D8*19511204~

DTP*AAH*RD8*20160901-20161030~

HI*ABK+R0600*APR+S06337A*APR+S29019A*APR+S238XXA*APR+S96919A~

NM1*DK*1*Y*ROGER*M**MD*XX*1740361906~

N3*5555 COVENAN*PO BOX 67432~

N4*COLUMBIA*SC*29204~

NM1*FA*2*ORGNAME*****XX*1255367637~

N3*456 MEMORIAL~

N4*SENECA*SC*29672~

HL*5*4*SS*0~

DTP*472*RD8*20160930-20161030~

SV1*HC+A0428+EP*36345.25*UN*30~

PWK*77*FX***AC*ESMDTESTATTACHMENTNUMBER5001~

SE*32*2100~

GE*1*2100~

IEA*1*000002100~

Figure 5: esMD_Sample_275_EDI_Batch_Request

ISA*00* *00* *ZZ*TEST123 *ZZ*111222333 *170320*1110*^*00602*000001100*0*T*+~

GS*PI*TEST123*111222333*20170320*1528*1*X*006020X316~

ST*275*0001*006020X316~

BGN*02*1703201110203*20170320*111001~

NM1*ACV*2*HIHPROVIDER*****XX*1234567893*67*1P~

PER*IC*ESMD TESTING*FX*8034362416*TE*8034362416*EX*6788~

NM1*40*2*COBIUS*****PI*11202*67*X3~

NM1*IL*1*PARKER*CARROL*S***MI*82345678A~

LX*1~

TRN*1* ESMDTESTATTACHMENTNUMBER5001~

HI*ABK+R0600*APR+S06337A*APR+S29019A*APR+S238XXA*APR+S96919A~

DTP*368*D8*20170320~

CAT*AE*MB~

OOI*1*47*ATTACHMENT~

BDS*B64*150421*

Sample Files


NA

NA

NA

NA

NA

NA

NA

NA

Sender Name

3577 Parkway Lane

Sample Files


Norcross

GA

30092

USA

~

SE*14*0001~

GE*1*1~

IEA*1*000001100~

Record of Changes


Appendix A: Record of Changes

Table 12: Record of Changes

Version

Number

Date Author/Owner Description of Change

1.0 04/05/2017 Kumar Sourabh Initial version

1.1 04/21/2017 Kumar Sourabh Resolved CMS comments.

1.2 05/02/2017 Nithin Gangula Resolved CMS comments.

Acronyms


Appendix B: Acronyms

Table 13: Acronyms

Acronym Literal Translation

ASC Accredited Standards Committee

B2B Business To Business

CAQH Council for Affordable Quality Healthcare

CDA Clinical Data Architecture

CMS Centers for Medicare & Medicaid Services CORE Committee on Operating Rules for Information Exchange

EDI Electronic Data Interchange

esMD Electronic Submission of Medical Documentation HI Health information

HIH Health Information Handler

HTTP Hypertext Transfer Protocol

HTTPS Hypertext Transfer Protocol Secure

MB Megabytes

MIME Multipurpose Internet Mail Extensions

NHIN Nationwide Health Information Network

NwHIN Nationwide Health Information Network

OID Organizational Identifier

PA Prior Authorization

RC Review Contractor

SOAP Simple Object Access Protocol

TBD To Be Determined

TR3 ASC X12 Standard for Electronic Data Interchange Technical Report Type 3

URL Universal Resource Locater

UTC Coordinated Universal Timestamp

WSDL Web Service Definition Language

XDR Cross-Enterprise Document Reliable Interchange

XML Extensible Markup Language

Referenced Documents


Appendix C: Referenced Documents

Table 14: Referenced Documents

Document Name Document Location and/or URL Issuance Date

Health Level 7 (HL7)-Clinical Data

Architecture (CDA) Implementation

Standards

http://www.hl7.org/implement/standards/index.

cfm?ref=nav

N/A

HIH Implementation Guide https://share.cms.gov/office/OFM/FMGS/DPS

S/esMD/esMD_HIH_Implementation_Guide_

AR2017.07.0.docx

05/02/2017

CAQH CORE X12 Document

Submission Service Interface

Specification

http://sequoiaproject.org/wp-

content/uploads/2014/11/caqh-core-x12-

document-submission-service-specification-

v1-0-508.pdf

03/06/2012

ASC X12N/006020X316 (275) TR3

Implementation Guide

http://store.x12.org/store/healthcare-4050-

5010-tr3-schemas

N/A

http://www.hl7.org/implement/standards/index.cfm?ref=navhttp://www.hl7.org/implement/standards/index.cfm?ref=navhttps://share.cms.gov/office/OFM/FMGS/DPSS/esMD/esMD_HIH_Implementation_Guide_AR2017.07.0.docxhttps://share.cms.gov/office/OFM/FMGS/DPSS/esMD/esMD_HIH_Implementation_Guide_AR2017.07.0.docxhttps://share.cms.gov/office/OFM/FMGS/DPSS/esMD/esMD_HIH_Implementation_Guide_AR2017.07.0.docxhttp://sequoiaproject.org/wp-content/uploads/2014/11/caqh-core-x12-document-submission-service-specification-v1-0-508.pdfhttp://sequoiaproject.org/wp-content/uploads/2014/11/caqh-core-x12-document-submission-service-specification-v1-0-508.pdfhttp://sequoiaproject.org/wp-content/uploads/2014/11/caqh-core-x12-document-submission-service-specification-v1-0-508.pdfhttp://sequoiaproject.org/wp-content/uploads/2014/11/caqh-core-x12-document-submission-service-specification-v1-0-508.pdfhttp://store.x12.org/store/healthcare-4050-5010-tr3-schemashttp://store.x12.org/store/healthcare-4050-5010-tr3-schemas

Structure BookmarksTable of Contents List of Figures List of Tables 1. Introduction1.1 Purpose 1.2 Scope 2. Use Case2.1 Assumptions 2.2 Actors and Roles 2.3 User Story Additional Documentation for Review 3. X12N 275 Process Flow4. Communication Protocol Specification4.1 CAQH CORE Batch Transaction Web Service Endpoints 4.2 CAQH CORE Envelope Specification 4.3 CAQH CORE Generic Batch Mode Messaging 4.4 CAQH CORE Metadata Information 5. ASC X12N275 Supplemental Information5.1 X12 Version Information 5.2 esMD-Specific Business Rules and Limitations 5.3 Clinical Document Information 6. Response Notification and Error Codes6.1 Interchange Acknowledgement (X12 TA1) 6.2 Implementation Acknowledgement (X12N 999) 6.3 Envelope Processing Status and Error Codes 6.4 Administrative Errors 7. Sample FilesAppendix A: Record of Changes Appendix B: Acronyms Appendix C: Referenced Documents

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